1. 1 Surgical Unit-Based Safety Program Proposed Resources for Partnership for Patients Terri Conner, Ph.D. Nybeck Analytics Partnership for Patients

2. 2 HOSPITALIZATIONS ARE RISKY In the U.S. – 7% of patients suffer a medication error – On average, every patient admitted to the ICU suffers an adverse event – 44,000 – 98,000 people die in hospitals each year as the result of medical errors – An additional 100,000 deaths from health-care associated infections – Cost of HAI is $28-33 billion

3. 3 SURGERY IS RISKY 25% of in-patient surgeries are followed by a complication, many leading to: – Prolonged LOS – Re-admission – Death 50% of all hospital adverse events are linked to surgery – At least 50% of adverse surgical events are preventable

4. 4

5. 5 PROJECT GOALS To achieve significant reductions in surgical site infection and surgical complication rates – Reducing complications reduces readmissions To achieve significant improvements in safety culture

6. 6 IMPORTANT POINTS Harm is preventable – Many HAIs and complications are preventable, and should be viewed as defects Technical and adaptive work – Focus on systems; not on individuals – Engage frontline staff to identify and fix local opportunities to improve

7. 7 SUSP Not Just a Checklist Program Informed by science – Medical best evidence – Social science Led by clinicians and supported by management Guided by measures

8. 8 SUSP INTERVENTIONS No single SSI prevention bundle – Dive deeply into SCIP measures to identify local defects – Emerging evidence Bowel prep Antibiotic redosing Chlorhexidine skin prep Capitalize on frontline wisdom to identify local opportunities to improve

9. 9 HOW WILL WE GET THERE? SUSP Technical component – TRIP: Translating Evidence into Practice Adaptive component – CUSP: Comprehensive Unit-based Safety Program

10. 10 SUCCESSFUL EFFORTS Michigan Keystone ICU program – Reduction in central line-associated blood stream infections – Reduction in ventilator-associated pneumonias

11. 11 TRIP: Translating Evidence Into Practice Summarize the evidence Identify local barriers to implementation Measure performance Ensure all patients get the evidence – 4 E’s Model

12. 12 4 E’S MODEL TO HELP IMPLEMENT PATIENT SAFETY INTERVENTIONS Engage – How does this make the world a better place? Educate – What do we need to know? Execute – What do we need to do? – What keeps me from doing it? – How can we do it with our resources and culture? Evaluate – How do we know we improved safety?

13. 13 CUSP Comprehensive Unit-based Safety Program An intervention to learn from mistakes and improve safety culture A good approach whenever there is a gap between evidence-based practice and current practice on your unit.

14. 14 CUSP: EMPHASIS ON CULTURE Shared attitudes, values, goals, practices, behaviors Culture influences behavior – Participation in quality improvement efforts – Communication Breakdown in communication contributes to nearly all adverse events.

15. 15 CUSP: COMPREHENSIVE UNIT- BASED SAFETY PROGRAM Safety practices part of daily work Implemented at the unit level Led by clinicians Structured program, yet flexible

16. 16 PRE-CUSP STEPS Assemble Safety Team – Multidisciplinary – Different levels of experience – Encourage joining team at any phase of the program

17. 17 PRE-CUSP STEPS Team Members – frontline staff – Project Leader (Unit Champion) – Nurse Manager – Physician Champion – Senior Hospital Executive – Patient Safety Coordinator – Epidemiology / Infection Control – Coach

18. 18 PRE-CUSP STEPS Measure Safety Culture – Before CUSP implementation, and then every 12-18 months – Use AHRQ’s The Hospital Survey on Patient Safety Culture (HSOPS) – All clinical and non-clinical providers – Report results to the unit and senior hospital executive

19. 19 CUSP STEPS 1. Science of safety training 2. Identify defects 3. Assign executive to adopt unit 4. Learn from defects 5. Implement teamwork tools

20. 20 STEP 1: SCIENCE OF SAFETY TRAINING Goals – Magnitude of patient safety problem – Foundation for investigating safety defects – Providers’ involvement significantly affects patient safety

21. 21 STEP 1: SCIENCE OF SAFETY TRAINING Learning Objectives – Safety is a property of the system – Use strategies to improve system performance Standardize work Create independent checks for key processes Learn from mistakes – Apply strategies to both technical work and team work – Teams make wise decisions with diverse and independent input

22. 22 STEP 1: SCIENCE OF SAFETY TRAINING Training Session – 3-part “Improving Safety” presentation by Dr. Peter Pronovost Part 1: http://www.youtube.com/watch?v=GOJJHHm7lnM Part 2 - http://www.youtube.com/watch?v=wpzb7nM6oFQ&feature=related http://www.youtube.com/watch?v=wpzb7nM6oFQ&feature=related Part 3 - http://www.youtube.com/watch?v=6BnXs4KtER8&feature=related http://www.youtube.com/watch?v=6BnXs4KtER8&feature=related – Instruct staff on reporting of safety concerns – Describe executive safety rounds

23. 23 STEP 2: IDENTIFY DEFECTS Eyes and ears of patient safety Ongoing process Disseminate Staff Safety Assessment Form Combine results and prioritize defects

24. 24 WHAT IS A DEFECT? Anything you do not want to have happen again. Many HAIs are preventable. They should be viewed as defects.

25. 25 STEP 2: IDENTIFY DEFECTS Staff Safety Assessment Form – Purpose: Tap into your knowledge and experiences at the frontlines of patient care to find out what risks are present on your unit that do or could jeopardize patient safety. – All health care providers in the unit complete this form. – 2-item questionnaire

26. 26 STEP 2: IDENTIFY DEFECTS Staff Safety Assessment Form 1. Please describe how you think the next patient in your unit/clinical area will be harmed. 2. Please describe what you think can be done to prevent or minimize this harm.

27. 27 STEP 2: IDENTIFY DEFECTS Combine Results – Group into common types of defects Communication Medication process Patient falls Supplies – Frequency distributions Example: communication, 57%

28. 28 STEP 2: IDENTIFY DEFECTS Prioritize safety concerns – Obtain input from CUSP team senior executive – Prioritize based on Likelihood of causing patient harm Severity of harm How common is the problem Likelihood it can be solved by implementing a daily work process

29. 29 STEP 4: LEARN FROM DEFECTS Four Key Questions 1. What happened? 2. Why did it happen? 3. What will you do to reduce the chance it will recur? 4. How do you know that you reduced the risk that it will happen again?

30. 30 WHAT HAPPENED? Reconstruct the timeline and explain what happened Put yourself in the place of those involved, in the middle of the event as it was unfolding Try to understand what they were thinking and the reasoning behind their actions/decisions Try to view the world as they did when the event occurred

31. 31 WHY DID IT HAPPEN? SYSTEM FAILURES Arise from managerial and organizational decisions that shape working conditions Often results from production pressures Damaging consequences may not be evident until a “triggering event” occurs Develop lenses to see the system factors that lead to the event

32. 32 WHAT WILL YOU DO TO REDUCE THE RISK OF IT HAPPENING AGAIN? Prioritize most important contributing factors Prioritize most beneficial interventions Safe design principles – Standardize what we do – Create independent check – Make it visible Safe design applies to technical and team work

33. 33 WHAT WILL YOU DO TO REDUCE THE RISK OF IT HAPPENING AGAIN? Develop list of interventions For each intervention: – Rate how well the intervention solves the problem or mitigates the contributing factors for the accident – Rate the team belief that the intervention will be implemented and executed as intended Select top interventions (2 to 5) and develop intervention plan – Assign person, task follow-up date

34. 34 HOW DO YOU KNOW RISKS WERE REDUCED? Did you create a policy or procedure? Do staff know about policy or procedure? Are staff using the procedure as intended? – Behavior observations, audits Do staff believe risks were reduced?

35. 35 STEP 4: LEARN FROM DEFECTS Summarize and Share Findings – Learning from Defects Tool Detailed form for each incident or identified defect – Case Summary Form Summarize the case Identify system failures Identify opportunities for improvement List actions taken to prevent future harm – Share your findings

36. 36 STEP 4: LEARNING FROM DEFECTS Key Points – Focus on systems, not people – Prioritize – Go mile deep and inch wide, rather than mile wise and inch deep – Pilot test – Learn from 1 defect a quarter – Answer the four questions

37. 37 STEP 5: TEAM WORK TOOLS Staff Safety Assessment Safety Issues Worksheet Status of Safety Issues Learning from Defects Tool Case Summary Form Briefings/Debriefings SSI Investigation Audits

38. 38 STAFF SAFETY ASSESSMENT Used to identify defects in the unit 1. Please describe how you think the next patient in your unit/clinical area will be harmed. 2. Please describe what you think can be done to prevent or minimize this harm.

39. 39 SAFETY ISSUES WORKSHEET Identified IssuePotential/ Recommended Solution Resourc es Needed Resources Not Needed 1. 2. 3.

40. 40 STATUS OF SAFETY ISSUES New and Ongoing DateSafety IssueContactStatusGoal New and Ongoing DateSafety IssueContactStatusGoal Completed DateSafety IssueContactStatusGoal

41. 41 LEARNING FROM DEFECTS Explain what happened. Check off the factors that negatively or positively contributed to the incident. Describe how you will reduce the likelihood of this defect happening again by completing the tables. Develop interventions, and choose 2-5 to implement. – What will be done? – Who will lead the intervention? – When is follow-up? Describe how you know you have reduced the risk. Summarize your findings using the Case Summary Form.

42. 42 CASE SUMMARY FORM Form Sections Safety tips Case summary System failures Opportunities for improvement Actions taken to prevent harm

43. 43 BRIEFINGS / DEBRIEFINGS Dominant tool for SUSP Growing evidence – Better team performance – Better safety culture – Reduction in delays Adapted to local hospital and OR Adapted to surgery type

44. 44 SSI INVESTIGATION TOOL Look into factors that may be systematically contributing to SSIs

45. 45 AUDITS Skin prep audits Antibiotic audits

46. 46 OTHER TOOLS Mislabeled specimens Wrong sided surgery Retained foreign objects

47. 47 SUSP IS A CONTINUOUS JOURNEY!!